Is the U.S. Ready for a Single-Payer Health Care System?
by Sandro Galea - Harvard Business Review - July 18, 2017
Ironically, as congressional Republicans have been trying to replace the Affordable Care Act, the ACA’s popularity is at an all-time high, and the majority of Americans now believe that it is the federal government’s responsibility to provide health care for all Americans. This shift in sentiment suggests that a single-payer system — a “Medicare for all” — may soon be a politically viable solution to America’s health care woes.
This system has long been an aspiration of the far left, yet even the right now seems to acknowledge its growing likelihood. Following his decision not to support the Better Care Reconciliation Act (BCRA), the Senate Republican leadership’s latest attempt to replace the ACA, Senator Jerry Moran, Republican of Kansas, warned in a statement: “[I]f we leave the federal government in control of everyday health care decisions, it is more likely that our health care system will devolve into a single-payer system, which would require a massive federal spending increase.” (The BCRA, which failed in the Senate, would have kept the basic contours of the ACA but greatly reduced its ability to provide care.)
Although congressional Republicans remain uncomfortable with universal coverage as a concept, some seem to understand that the American people are coming to see health care as a right. It is very difficult to imagine how universal coverage could be sustainable over the long run without a central payment system.
While there may be openings for bipartisan compromise to address the weaknesses of the ACA, the core of the ACA framework is unstable — a hostage to the marketand political fortune. By contrast, a single-payer model stands to be much more durable and provides a chance to build a health care system around the well-being of patients rather than the profits of providers and insurers. Thirty-three percent of the American public now support a single-payer system — a 5% increase since January.
To be sure, some important players remain opposed to a single-payer system. One is the American Medical Association. It favors an ACA-like structure that subsidizes insurance for low-income individuals and families, and argues that a single-payer system would stymie private-sector innovation, create long waiting periods, and offer less patient choice. However, the AMA is far from a disinterested party. Indeed, it was an early resister of alternatives to our current fee-for-service system, fearing a more progressive model could diminish the independence and entrepreneurial capacity of its members.
Not surprisingly, insurance and pharmaceutical industries, which have a strong economic self-interest in maintaining the status quo, are also against the single-payer model. Opponents warn that a single-payer model could lead to a wholesale bureaucratization of the health care system by the federal government, or even to socialized medicine.
But are these concerns warranted? Doctors who fear losing their autonomy need only look north to see how a single-payer system can work without encroaching on the independence of physicians. Canada has had a single-payer model for decades, and there’s no government takeover of its health care system in sight. Most services are still provided by the private sector, and most physicians are still self-employed. While health expenditures remain high, Canadians nevertheless enjoy better health outcomes at lower cost than the United States, whose population’s health is mediocre despite ever-higher spending on medical care.
Canada’s success stems from a few basic tenets. Its system is structured around a federal requirement to provide coverage for necessary services such as doctor and hospital visits. While the cost of this care is covered by the taxpayer, the task of providing it is decentralized to each of the country’s 13 provinces and territories. Each region has wide latitude to innovate — as long as it honors the basic guarantee of providing free point-of-care treatment to all citizens for certain essential services, funded through a central payer. This is an important point. The single-payer approach is often characterized as a gateway to Byzantine regulation. Yet the reality is it is a fundamentally simple, even elegant, concept: Everybody gets the coverage that everybody pays for. Within this framework, there is much room for maneuver.
If implemented correctly, a centralized payment structure can create a health care system that is genuinely organized around health. It may seem counterintuitive to suggest that the U.S. system is not organized around health, but this truth has long been obvious to anyone who follows this issue or to anyone who has ever had to seek care in a time of need. Over and over, we have seen how the U.S. health care system produces a vast array of increasingly expensive drugs and treatments that few can access without high-quality insurance.
A single-payer model could change this — not by nationalizing health care outright but by incentivizing new payment structures such as bundled payments, accountable care organizations, and other population-based models. Unlike a fee-for-service arrangement, these models do not tether provider compensation to the frequency and expense of care. Bundled payments — which provide a fixed-dollar amount for a particular type of care (e.g., replacing a knee) delivered over a set period of time — would encourage greater efficiency in care by having providers compete on the basis of quality and price. And capitation, by compensating providers per assigned patient, would open the door to an increased focus on prevention, which would save time and resources.
While such innovative payment models are possible within the current fragmented payer system — indeed, the Centers for Medicare and Medicaid Services has been a leader in innovating — a single-payer system immediately creates an opportunity for wide-scale adoption of new approaches that can transform health in the United States. With a health system reoriented toward stopping disease before it starts, rather than treating it once it strikes, we may even start to see more health investments go beyond health care, targeting the social, economic, and environmental factors that create the conditions for disease in society.
Decades of opposition have tinted Americans’ view of a single-payer system’s potential. But there is no reason to think that the status quo is immutable. It did not, after all, come about organically; it is the product of years of influence strategically wielded by powerful stakeholders in business, medicine, and politics. These stakeholders were able to advance their agenda in large part because Americans had not come to view health care as an essential collective right. This is changing. Turning this growing view into policy will require a national agreement that health care is a value worth paying for. The country is not there yet, but it no longer feels that far off.
by Dan Balz - Washington Post - July 19, 2017
By any measure, the collapse of the Senate health-care bill represents an epic failure for the Republican Party and a major embarrassment for President Trump. The crusade that animated — and bound — conservatives for seven years proved to be a mirage, an objective without a solution. Power comes with consequences.
There is no way to spin to those who were promised that the Affordable Care Act would be repealed and replaced once Republicans held full power in Washington that what has happened is the fault of forces outside the party. This has been a GOP undertaking from start to finish. It is as though Republicans unknowingly set a trap and then walked into it without having prepared escape routes.
What price, if any, Republicans will pay for this setback will be revealed over the coming months. Perhaps they will be able to move quickly on other priorities — a tax bill being the most appealing now, although not necessarily a slam dunk — and wash away the bitter taste of the health-care debate. That might be the best they can hope for, but there are no guarantees.
The failed promise to repeal and replace Obamacare surely will affect the mood and enthusiasm of the Republican base heading toward 2018. When the Gallup organization asked Americans about the future of the Affordable Care Act recently, 30 percent overall said they favored “repeal and replace,” but 70 percent of Republicans supported that option. GOP lawmakers will have left them empty-handed, perhaps disillusioned. That will energize Democrats even more in their quest to take control of the House in 2018.
The Senate Republicans' effort to overhaul the nation's health-care system collapsed on July 17 and 18, when multiple Republican senators came out against both the revamped bill and President Trump's suggestion of repealing Obamacare and letting the markets "fail" before replacing it. (Video: Jenny Starrs/Photo: Melina Mara/The Washington Post)
The breakdown that has been on display over the past weeks also cannot help but bring more attention to divisions inside a Republican Party whose coalition has been reshaped by the rising voice of white working-class voters who helped put Trump in the Oval Office. All parties have divisions, but what Republicans must reckon with is not simply a conflict between conservatives and moderate-conservatives, but differences rooted in potentially incompatible perceptions of government and Washington.
The president spent Tuesday morning tweeting his frustrations, blaming Democrats and “a few Republicans” for what happened in the Senate. “We will return!” he said in one tweet. “Stay tuned!” he said in another. Let Obamacare fail, he proclaimed. Those are standard exhortations by the president, meant to shore up his supporters, but they carry no particular force with those in his party who have been doing the heavy legislative lifting.
Instead, those tweets underscored the futility of trying to make what happened on health care anything other than what it was: a self-inflicted wound by a party that succumbed to the easy appeal of campaign slogans without doing the hard work of policymaking over the past seven years.
William Galston of the Brookings Institution noted Tuesday that the health-care debate showed anew that Republicans have not bridged the gap between campaigning and governing. This has been a longtime problem for a party that is at best ambivalent about the federal government and at worst openly anti-government, at least rhetorically. This condition existed before Trump came on the scene. It has worsened because of his political success.
Trump’s rise and his victory in the presidential campaign intensified a point of internal conflict for the Republicans, one that pits hard-line, anti-government conservatives against many of those working-class voters who believe in the federal programs that deliver services to them and don’t want them eliminated.
“The Republican Party is grappling with the fact that conservative orthodoxy is one thing and populism is another,” Galston said. “Populists are not anti-government. Populists are in favor of government that helps people like them.”
The president’s embrace of the Republican promise to repeal and replace the Affordable Care Act was and is incompatible with political views he often stated as a candidate. He adopted the rhetoric of repeal and replace, but whenever he talked about health-care policy, he did not sound like a conservative Republican. He wanted coverage for everyone. He didn’t want to hurt people. He didn’t want to make cuts to entitlement programs, whether Medicare, Medicaid or Social Security.
What Trump espoused clashed with what conservative, small-government Republicans long had been preaching. In office, his ambivalence has been evident at virtually every turn in the debate. He complained about the House bill as too mean after publicly praising it. He wanted repeal and replace without any pain. He wanted a victory but could not engineer it.
Republicans have experienced two well-known lessons. Tackling big issues on a partisan basis is fraught with political risk. And once government benefits are extended to tens of millions of Americans, taking them away is as risky politically as it is substantively difficult.
After seven years of the Affordable Care Act, despite its flaws and weaknesses, Republicans were forced to concede that parts of the law were extremely popular. Trying to keep the good while fulfilling a promise to get rid of the measure called for legislative and policy gymnastics beyond their capability.
That a repeal-and-replace effort failed is all the more disheartening for Republicans, given what appeared at the start of the year to be an almost-ideal set of players to carry it to passage. It started with Trump, who had a megaphone, as do all presidents, and a reputation as a skilled dealmaker, and who came to office claiming that he alone could fix things.
In the House, Republicans were led by Speaker Paul D. Ryan (Wis.), who was long considered enough of a policy expert to be entrusted to develop an alternative to Obamacare that could match the party’s goals and produce a legislative majority.
In the Senate, Republicans were led by Majority Leader Mitch McConnell (Ky.), regarded not as a policy wonk but as a shrewd and tough-minded legislative strategist, the best of a generation, someone who could shepherd a bill through the legislative maze, if anyone could.
Ryan, after false starts, managed to get a bill through his chamber, but it was flawed enough that Senate leaders knew they would have to change it. McConnell tried with different versions but overreached. He couldn’t find the legislative magic many assumed he would be able to employ. And the president proved not to be a dealmaker.
Trump tried to walk away from the mess on Tuesday. “Let Obamacare fail,” he said. “It will be a lot easier.” He said Democrats would own that failure, if that is the case. He said he would not own it, regardless. Republican lawmakers will take all that in and recognize, as they already know, that the president will claim any victories they produce for him and run from any defeats, but he is not likely to be the architect of a policy that will match his campaign rhetoric.
There also will be a period of recrimination in the wake of what happened in the Senate. If that spills into the debate over a tax bill, there could be more trouble ahead. The six-month battle over health care has been a time waster and a tone setter. Leaders must regroup, and quickly.
In normal times, a party would look to its president to hasten the healing process and pick up the pieces. But these are not normal times. Trump operates by his own standards. And this is a Republican Party that has yet to come to terms with what it has become and what is expected of a majority party.
‘It’s an insane process’: How Trump and Republicans failed on their health-care bill
by Robert Costa, Kelsey Snell and Sean Sullivan - Washington Post - July 18, 2017
Vice President Pence arrived at the National Governors Association summer meeting with one mission: to revive support for the flagging Republican plan to rewrite the nation’s health-care laws.
He failed.
Instead of rousing cheers on the waterfront in Providence, R.I., Pence was greeted with an icy air of skepticism Friday as he pitched the legislation, which would reduce federal Medicaid funding and phase out coverage in dozens of states.
By Monday evening, when President Trump and Pence gathered a cluster of GOP senators in the Blue Room of the White House over plates of lemon ricotta agnolotti and grilled rib-eye steak, the measure was all but dead.
“The president talked about France and Bastille Day,” Sen. Steve Daines (R-Mont.) said in an interview Tuesday, recalling the president’s tales during dinner of parades and pomp from his recent trip to Paris.
Daines described the group’s conversation, which also touched on issues ranging from health care to the debt limit, as loose — as if Trump “sat down and went out to dinner with friends, acquaintances, people you work with. It was just dinner to talk about what’s going on.”
As the dinner ended, reality returned. Two more Republican senators had suddenly bolted from supporting the health-care bill, lifting the total number of Republicans opposed to four and effectively killing it.
“I was very surprised when the two folks came out last night,” Trump told reporters Tuesday. “We thought they were in fairly good shape.”
Yet the dramatic collapse of the GOP proposal in the Senate was hardly a shock to most, especially those intimately involved in a venture that has been stalled and fitful since the House passed its version in May.
The upheaval Monday night was a tipping point after weeks of burbling discontent within the party about whether passing the legislation made sense. Nearly every GOP senator was eager to check the box of repealing and replacing the Affordable Care Act they had long opposed — but many were also distressed by the possible costs of upending a law that has grown deep roots in states, risen in popularity and is relied upon by some Republican governors.
Moderates were always skittish about the drastic Medicaid cuts opposed by many of their governors. Conservatives were always unhappy with the scope of the Senate’s legislation, which they felt did not go far enough to gut the law.
And Trump was frequently disengaged, sporadically tweeting and making calls to on-the-fence senators but otherwise avoiding selling the bill at the kind of big rallies that he often holds on issues he champions.
“It has been obvious to me for some time, and likely obvious to the leaders, that up to 10 Republicans were uncomfortable with the bill and were thinking about voting against the motion to proceed,” Sen. Susan Collins (R-Maine), a critic of the bill, said in an interview Tuesday. “So it’s surprising to me that after the administration failed to win over the governors this past weekend, there wasn’t more of a recognition of the fact that the bill was probably in fatal trouble.”
Senate Majority Leader Mitch McConnell (R-Ky.), who has long cultivated a reputation as a canny operator, found it nearly impossible to wrangle together his conference amid the mounting concerns. He could offer them tweaks and adjustments but not the political cover that they coveted.
Neither could the White House, which kept tabs on GOP senators but did not drive the negotiations at all.
“None of us knew what the meeting was about last night. We just were invited to the White House,” Daines said. “There was no topic given to us.”
Still, a false sense of confidence from the White House and Senate GOP leadership came to define the entire process. Each day seemed to bring a wave of new assertions that Senate Republicans were committed to fulfilling what has been the party’s signature pledge for nearly a decade — and then there would be new twists that threatened that ambition.
With Trump engulfed in the fallout from investigations of Russian interference in the 2016 campaign, Pence became the Trump administration’s main advocate for the legislation. He went to Senate lunch after Senate lunch, and eventually to the governors’ meeting.
But Pence, like the bill, never caught on.
While Pence has clout with conservatives nationally, he drew blank stares from those in front of him in Rhode Island — despite being a former Indiana governor. When he targeted Ohio Gov. John Kasich (R), who opposed the bill, he sparked outrage for appearing to incorrectly link waiting times for disabled people in Ohio to the expansion of Medicaid.
Kasich was newly furious about the hardball tactics. Other influential GOP critics of the bill, such as Nevada Gov. Brian Sandoval, also would not budge, in turn keeping Sen. Dean Heller (R-Nev.) almost certainly in the “no” camp.
“This is a dramatic change to what most of us have reacted to within the last four years,” Sandoval told reporters over the weekend. He likened the health-care push to shaking an Etch-a-Sketch.
Connecticut Gov. Dan Malloy (D), who attended the governors’ conference, summed up the Democratic view in a Tuesday interview: “If he’s treating a Republican governor in Ohio that way, how would he treat me?”
Malloy singled out a private breakfast session Saturday, in which administration officials sought to win over governors on the Senate legislation, as particularly problematic for the White House’s sale. He said one official sought to discredit the Congressional Budget Office; less than a minute later, another official cited a CBO statistic to defend his argument.
“It was heavy handed. It was ham-handed,” Malloy said of the administration’s approach at the summit.
The CBO had been set to release another report as soon as Monday on what the bill would do to insurance coverage levels, premium costs and the federal budget deficit. But it ended up not being released. A CBO report on an earlier version of the legislation projected that it would result in 22 million fewer Americans with insurance by 2026 than under current law.
Delays in the past week gave opponents of the bill more time to protest, over the July 4 recess and again this week due to Arizona Republican Sen. John McCain’s surgery.
Inside the West Wing, Pence and Trump advisers continued to operate as if passage was possible, regardless of the unsuccessful turn in Providence. When the dinner convened Monday, Pence was scheduled to dine at his residence later that week with undecided Republicans.
Regardless of the negative feedback, the White House believed that the NGA meetings went as well as they could have expected considering that the governors were expected to be clamoring for more federal money than the bill would provide. Pence and Health and Human Services Secretary Tom Price — both former House members — teamed up on the call list, wooing Sunday and Monday by phone.
Among the members who were being monitored closely by Pence was Sen. Mike Lee (R-Utah), according to a person familiar with the negotiations. In multiple discussions with Pence, Lee indicated that he had reservations but was not a firm “no” and was open to further talks.
But it was Lee and Sen. Jerry Moran (R-Kan.) who ended up announcing their opposition on Monday night as Pence and Trump dined with other lawmakers at the White House — a final, vivid reminder of how the rosy view among many senior Republicans rarely, if ever, tracked with the actual state of play.
Lee and Moran made it four Republican “no” votes. They joined Sen. Rand Paul (Ky.) and Collins, who had declared their opposition days earlier. With a 52-seat majority, Republicans could afford to lose only two votes to pass the bill since all 46 Democrats and two independents were expected to vote against the proposal, with Pence as the potential tiebreaker.
One sign that the White House and McConnell didn’t see it coming: the senators who were in the Blue Room on Monday night. They were not holdouts but mostly heavyweights of the Republican leadership: Sens. John Cornyn (Tex.), Lamar Alexander (Tenn.), and Roy Blunt (Mo.), among others.
Trump, impatient with the Senate’s glacial pace, asked for a candid assessment of the legislation’s status from the veteran lawmakers, according to officials familiar with the meeting. He implored them to hurry up and get the bill to his desk. But it was Paris and the flag-waving festivities he had witnessed alongside French President Emmanuel Macron on Thursday and Friday that occupied much of his attention during the conversation, the officials said.
As difficult as the health-care debate had been, there was a pervasive feeling that McConnell would somehow prevail.
“I wouldn’t put it on him,” Sen. Marco Rubio (R-Fla.) said on Tuesday about Trump. “The bottom line is there are members here who understood the president’s preference and were willing to vote against it anyways.”
Some Senate Republicans said McConnell’s strategy of working an inside game and largely leaving Trump to observer-cheerleader status was misguided from the start. Sen. Ron Johnson (R-Wis.) said the public should have been far more informed about the bill.
“We didn’t have the courage to lay out exactly what caused premiums to increase,” Johnson said. “We don’t even have the [CBO] score on this latest version. It’s an insane process. If you don’t have information how can you even have a legitimate discussion and debate?”
Tuesday brought more tension. There was finger-pointing and faction-forming as Pence and White House Chief of Staff Reince Priebus worked to repair relationships with senators, many of whom saw the president and his team as perhaps well-intentioned but fumbling in their understanding of Congress.
During a Senate lunch, when McConnell broached voting Wednesday on a bill that would simply repeal Obamacare, he was met with resistance, according to aides familiar with the meeting. McConnell had speakers lined up to support his plan, but a number of senators, fuming over the Monday drama and other issues, asked for a pause rather than quick legislative action.
After the lunch, McConnell did not say when a health-care vote would happen, other than the “near future.” By the end of the day, he said it would happen “early next week.”
The Post-Republican Obamacare Market Will Be "Stable" and Very Profitable for Health Insurers
by Bob Laszewski - Health Policy and Marketplace Blog - July 18, 2017
Predictions that the individual health insurance market will now implode are misplaced.
First, in the wake of the Republican collapse of efforts to replace Obamacare, Medicaid will continue on unaffected. The Obama Medicaid expansion is fully funded for years to come. The nineteen states that did not take the expansion will continue to be on the outside looking in as their taxpayers continue to fund the expansion in the 31 states that did expand. And, health insurers will continue to enjoy that growth in their business as states continue to benefit from the open-ended federal funding.
The individual health insurance market will not collapse.
With about 3,000 counties in the U.S., I can't give you an absolute guarantee that there won't be a few that will not have an insurance carrier serving the Obamacare market in 2018. But generally, the vast majority of people eligible for subsidies will have at least one carrier to buy from.
The Kaiser Family Foundation is out with a recent study looking at medical loss ratios in the first quarter of 2017. They concluded that "individual market insurers on average are on a path toward regaining profitability in 2017."
I wouldn't go so far as to say that participating health plans will generally make money in 2017––the first quarter medical loss ratio is always better early on as consumers satisfy their ever-growing Obamacare deductibles.
But I do think 2018 could be a decent bottom line year for most Obamacare exchange insurers. And, 2019 should be just fine.
Does this mean the Obamacare insurance exchanges are working well?
No.
If the stability and success of Obamacare is measured by insurance company profitability things are improving.
But if stability and success is measured by how the Obamacare insurance exchanges are impacting the people who have no other place to go for their health insurance, this program remains a disaster for at least the 40% of the market that are not eligible for subsidies.
First, Obamacare is a tale of two cities.
Health plans have all but given up on getting a healthy risk pool under Obamacare. After four successive open enrollments run by the Obama administration, the program never got close to the percentage of the eligible pool needed to be successful.
The carriers looked at this landscape and concluded the only viable strategy was to just keep boosting the rates until they reach profitability. And, that is what they have been doing and that is why their medical loss ratios are starting to improve.
But that has meant huge premiums and deductibles. It is now not uncommon to see the lowest cost unsubsidized plan in a market for a family cost at least $1,000 a month, $12,000 a year, with an individual deductible in the $6,000 to $7,000 range. I have seen many areas where the lowest premium is already at $1,500 a month, $18,000 a year. Even for upper income families this is intolerable with premiums well over 10% of their gross income and deductibles making the plans useless to all but the sickest.
This is what the Kaiser Family Foundation would call stable: "The individual insurance market has been stabilizing in most of the country and could continue just fine."
The big political irony is that it is not the traditional Democratic constituency––lower income people in Medicaid or eligible for exchange subsidies––that are getting hurt. It is the upper income people not eligible for any benefits that more often voted for Trump and this Republican Congress that are getting left out as the health plans raise their rates toward profitability.
Even if Trump kills the $7 billion in annual payments to the health plans for the lower-income cost sharing subsidies it will not alter this trajectory. The carriers will simply respond by increasing their rates as of January 2018 to be able to fund the low-income cost sharing subsidies they are required to give people under the Obamacare law.
Obamacare is not healthy. Premiums and deductibles will continue to rise because the pool is out of balance with too many sick people for the number of healthy that have signed up. That will only get worse as the unsubsidized get priced out of the market.
But health insurers will focus their business on what will be for them the ideal market––people immune to what they, or the taxpayer, have to pay for the product.
The people who are and will be getting hurt badly will be the higher income ones who more often vote Republican.
But, Obamacare is well on its way to "stability."
But it is a bizarre form of stability.
And, this will not change until this or another Congress and President change it.
First, in the wake of the Republican collapse of efforts to replace Obamacare, Medicaid will continue on unaffected. The Obama Medicaid expansion is fully funded for years to come. The nineteen states that did not take the expansion will continue to be on the outside looking in as their taxpayers continue to fund the expansion in the 31 states that did expand. And, health insurers will continue to enjoy that growth in their business as states continue to benefit from the open-ended federal funding.
The individual health insurance market will not collapse.
With about 3,000 counties in the U.S., I can't give you an absolute guarantee that there won't be a few that will not have an insurance carrier serving the Obamacare market in 2018. But generally, the vast majority of people eligible for subsidies will have at least one carrier to buy from.
The Kaiser Family Foundation is out with a recent study looking at medical loss ratios in the first quarter of 2017. They concluded that "individual market insurers on average are on a path toward regaining profitability in 2017."
I wouldn't go so far as to say that participating health plans will generally make money in 2017––the first quarter medical loss ratio is always better early on as consumers satisfy their ever-growing Obamacare deductibles.
But I do think 2018 could be a decent bottom line year for most Obamacare exchange insurers. And, 2019 should be just fine.
Does this mean the Obamacare insurance exchanges are working well?
No.
If the stability and success of Obamacare is measured by insurance company profitability things are improving.
But if stability and success is measured by how the Obamacare insurance exchanges are impacting the people who have no other place to go for their health insurance, this program remains a disaster for at least the 40% of the market that are not eligible for subsidies.
First, Obamacare is a tale of two cities.
- The lower-income people who are eligible for Medicaid as well as the people who make less than 400% of the federal poverty level and are therefore capped in how much they will pay for health insurance––these people are doing fine.
- The 40% of the U.S. population that live in households that make more than 400% of the federal poverty level and get no premiums subsidies and pay the full cost of premiums, out-of-pocket costs and any big rate increases––these people are getting clobbered.
Health plans have all but given up on getting a healthy risk pool under Obamacare. After four successive open enrollments run by the Obama administration, the program never got close to the percentage of the eligible pool needed to be successful.
The carriers looked at this landscape and concluded the only viable strategy was to just keep boosting the rates until they reach profitability. And, that is what they have been doing and that is why their medical loss ratios are starting to improve.
But that has meant huge premiums and deductibles. It is now not uncommon to see the lowest cost unsubsidized plan in a market for a family cost at least $1,000 a month, $12,000 a year, with an individual deductible in the $6,000 to $7,000 range. I have seen many areas where the lowest premium is already at $1,500 a month, $18,000 a year. Even for upper income families this is intolerable with premiums well over 10% of their gross income and deductibles making the plans useless to all but the sickest.
This is what the Kaiser Family Foundation would call stable: "The individual insurance market has been stabilizing in most of the country and could continue just fine."
The big political irony is that it is not the traditional Democratic constituency––lower income people in Medicaid or eligible for exchange subsidies––that are getting hurt. It is the upper income people not eligible for any benefits that more often voted for Trump and this Republican Congress that are getting left out as the health plans raise their rates toward profitability.
Even if Trump kills the $7 billion in annual payments to the health plans for the lower-income cost sharing subsidies it will not alter this trajectory. The carriers will simply respond by increasing their rates as of January 2018 to be able to fund the low-income cost sharing subsidies they are required to give people under the Obamacare law.
Obamacare is not healthy. Premiums and deductibles will continue to rise because the pool is out of balance with too many sick people for the number of healthy that have signed up. That will only get worse as the unsubsidized get priced out of the market.
But health insurers will focus their business on what will be for them the ideal market––people immune to what they, or the taxpayer, have to pay for the product.
The people who are and will be getting hurt badly will be the higher income ones who more often vote Republican.
But, Obamacare is well on its way to "stability."
But it is a bizarre form of stability.
And, this will not change until this or another Congress and President change it.
The Trumpcare Bonfire
by The Editorial Board - NYT - July 18, 2017
It will come as a huge relief to millions of Americans that Republican lawmakers have struck out in their attempts to destroy the Affordable Care Act — at least for now. But this ideological exercise in futility has already done great damage to the health care system.
First the good news, which came in two installments: No. 1, the Senate’s health care bill — which would have stripped 22 million people of their health insurance and increased premiums for older Americans and those with pre-existing conditions — collapsed Monday. Then, Tuesday, Mitch McConnell’s plan to repeal much of Obamacare without a replacement also fell apart as senators defected.
Now the bad news: While the Affordable Care Act is not collapsing, the Senate and House health bills and President Trump’s promises to sabotage the A.C.A. have destabilized some of the health insurance marketplaces created by that law. Nearly 40 counties in Indiana, Nevada and Ohio are at risk of having no insurers participating in the marketplaces next year; other counties will have only one company offering policies.
In addition, policies sold in the marketplaces could cost a lot more if the Trump administration carries out its threats to stop providing subsidies to insurers to lower deductibles for low-income and middle-income people. It can do that through administrative action. House Republicans sued the Obama administration to block the payments on grounds that Congress had not voted separately to appropriate the money, even though the A.C.A. had authorized them.
So far, Mr. Trump is viewing health care policy through the same narrow lens he uses for everything: his political standing. On Tuesday, he blamed Democrats for obstructing repeal and said that Republicans should “let Obamacare fail” in order to have another shot at replacing it, as if the health of millions of Americans wasn’t at stake. Compare that to what Senator Shelley Moore Capito of West Virginia saidabout her decision not to support a repeal-and-delay bill: “I did not come to Washington to hurt people.” The question now is which approach Congress will take.
Under the humane approach, with a stronger health care system a shared goal, Republicans and Democrats would work together to fix the marketplace problems and restore confidence among insurance companies. In counties with no insurers, Congress could require the Federal Employees Health Benefits Program to offer coverage. State governments, working with the Trump administration, could create reinsurance programs to reduce the risk that insurers would lose money because of a few very sick patients. This could lower premiums and encourage insurers to operate in sparsely populated parts of the country.
If it chooses to set partisan point-scoring aside, the Trump administration would continue subsidy payments to insurers, House Republicans would drop their lawsuit and, going forward, Congress would appropriate money for these payments so that they could not be used to undermine the health care law. Quick action is needed on all fronts because insurers and state and federal regulators must finalize rates and policies for next year in the coming weeks.
In the longer term, the 19 states that have refused to expand Medicaid under the A.C.A. ought to reconsider. The program helps lower-income, older and disabled people, with positive results for beneficiaries and the economy. It reduces uncompensated care at hospitals, and the people who receive treatment are healthier and more productive. About four million people could gain coverage if these last states expanded Medicaid, making it a big win for the country.
John Kasich: The Way Forward on Health Care
by John Kasich - NYT - July 18, 017
Columbus — Washington’s approach to health care over the past decade is yet another example of our lawmakers’ increasing distance from the rest of America. First one party rams through a rigid, convoluted plan that drives up costs though unsustainable mechanisms that are now unraveling. Then the other party pursues fixes that go too far the other way — and again ignores ideas from the other side.
Neither extreme is cutting it, and the quick opposition that doomed the Senate plan reflects how unacceptable its ideas are to so many. The American people want and deserve reasonable, balanced, sustainable health care so that they can live without the fear of bankruptcy if they get sick, our most vulnerable neighbors are treated with compassion and those who seek to improve their lives can get healthy, confront addiction and get work.
Despite weeks of hard effort, the Senate plan was rejected by governors in both parties because of its unsustainable reductions to Medicaid. Cutting these funds without giving states the flexibility to innovate and manage those cuts is a serious blow to states’ fiscal health at a time when most — Ohio included — are feeling headwinds from a softening national economy. And, unlike the federal government, states must balance their budgets. Particularly problematic was the bill’s failure to adequately meet addiction and mental health needs — which often occur together. Diverting funds away from the comprehensive, integrated physical and mental health care that is proving effective is a step backward.
The Senate plan also failed to repair Obamacare’s damage to the insurance markets. Insufficient tax credits would make coverage unaffordable for many lower income Americans: Two of the subsidies in the bill would be temporary and a third would likely be unsustainably underfunded. Congress should avoid doing anything likely to cause further instability in the huge and complex private insurance market.
In the uncertainty created by the Senate plan’s collapse, Congress should guard against a hasty next step. Just taking up the fatally flawed House plan is not an answer, and this idea should be immediately rejected for the same reasons senators rejected the Senate’s own proposal. Also, simply repealing Obamacare without having a workable replacement is just as bad. Both would simply yank health coverage out from under millions of Americans who have no other alternative.
After two failed attempts at reform, the next step is clear: Congress should first focus on fixing the Obamacare exchanges before it takes on Medicaid. If we want to move Americans off Medicaid, there must be somewhere stable for them to go. For all its faults, at least Medicaid is currently a stable system for those who need it. The exchanges are anything but, and need immediate improvements.
One vital improvement would be to provide adequate tax credits, which would help keep health plans in the individual market and encourage — not undermine — robust competition. Companies should also be required to continue following reasonable guardrails like ensuring minimum coverage that is genuinely useful and covers pre-existing conditions. Once we see these repairs taking hold, Congress should then take up needed improvements to Medicaid as part of comprehensive entitlement reform.
States are willing to assume greater financial risk by transitioning to a block grant or per-capita cap, but will also need new flexibilities, such as tools to manage the rising cost of pharmaceuticals — the fastest growing component of Medicaid. And states cannot expect the federal government to continue paying 90 percent of Medicaid expansion costs given our nation’s historic debt; they must accept a gradual return to traditional cost-sharing levels.
Finally, we can never truly fix the rising cost of health care unless we start paying for value rather than volume. We are making this transition in Ohio by paying physicians for providing better care, not simply more care, in order to pursue better health outcomes.
In resetting health care reform in these ways — and I don’t rule out that other, balanced approaches bear consideration also — Congress can surmount the fatal flaws of both Obamacare and the current approaches: the reflection of a single partisan point of view. Health care policy is only partisan in the abstract. When you or your loved one is sick and needs care, ideology is irrelevant; getting well is all that matters. That same common sense must be reflected in the way we fix Obamacare. Another one-sided plan, driven hard by one party against the wishes of another, can never succeed because it will essentially maintain the status quo: partisan opposition and no real solutions.
The best next step is for members of both parties to ignore the fear of criticism that can come from reaching across the aisle and put pencil to pad on these and other ideas that repair health care in real, sustainable ways. America needs it, and I know that a bipartisan group of governors, including myself, stands ready to help in any way we can to provide an affordable, sustainable and responsible system of health care for the American people.
The Health Care Collapse Is a Victory for the Truth
by David Leonhardt - NYT - July 18, 2017
After Donald Trump won the presidency, many Americans despondently wondered whether facts mattered anymore.
Trump, after all, won the presidency despite a constant stream of falsehoods. He launched his political career with a lie about Barack Obama’s birthplace and just kept on lying, about almost every imaginable subject. He also admitted to being a sexual molester. He refused to release his tax returns, unlike every other modern nominee. And yet he was elected president of the United States. There was, and still is, ample reason for despondence.
But the events of the past few months, and especially the last few days, offer some reason for encouragement. They have demonstrated that facts still matter and that truth has some inherent advantages over falsehood. That’s the No. 1 lesson to take from the collapse of the Republican health care bills.
In trying to pass a bill, Trump and his Capitol Hill allies had some big advantages. They controlled every branch of the federal government, and they were willing to ignore decades-old congressional traditions, such as holding public hearings when writing major legislation.
They had only one big weakness, in fact: They weren’t dealing in reality.
They had spent years making up untruths about Obamacare. They said it was written behind closed doors, even though it wasn’t. They said it was a big-government takeover, when it was actually a combination of conservative and liberal ideas. They said it was collapsing, when in fact it has mostly worked well — and its flaws, while real, are eminently fixable through bipartisan legislation.
Those arguments served Trump, Mitch McConnell and Paul Ryan very well when they were running political campaigns. Once they took power, however, they had a problem.
They didn’t have a real-world health care plan. They had a set of talking points. When they tried to turn those talking points into a bill, the result was a disaster. It would have taken insurance coverage from millions of people and worsened coverage and raised costs for millions more, many of them Republican voters.
Experts from across the ideological spectrum belittled their bill. The nonpartisan Congressional Budget Office dispassionately explained the damage it would do. Groups representing doctors, nurses, retirees, hospitals, insurers and people with cancer, diabetes, heart disease, lung disease and birth defects all opposed the bill.
In the House, Ryan and his leadership team were still able to jam through legislation, in a display of partisan loyalty. In the Senate, the famously crafty McConnell kept most of his 52 caucus members on board. But he could not lock down the 50 he needed.
He had a reality problem.
Too many Republican senators understood that the bill’s defenders could make up fictions about it for only so long. And those defenders certainly tried. In the last few days alone, both Vice President Mike Pence and Tom Price, the secretary of health and human services, made blatantly untrue claims about the bill’s contents.
But, thank goodness, a handful of senators understood that they wouldn’t be able to create their own reality forever. Eventually, real people would lose real health insurance and be denied real medical care for their illnesses.
“I did not come to Washington to hurt people,” Senator Shelley Moore Capito, of West Virginia, said Tuesday, helping to doom the latest bill. Lisa Murkowski, of Alaska, explained, “This just creates more chaos and confusion.” Susan Collins, of Maine, cited the “deep cuts” to Medicaid coverage — the same cuts Pence and Price had tried to deny.
I remain worried that Trump may somehow make another run at shrinking health insurance coverage. But his basic problem isn’t going away. Facts still matter.
They’ve won a resounding victory this week.
‘Let Obamacare Fail,’ Trump Says as G.O.P. Health Bill Collapses
by Thomas Kaplan - NYT - July 18, 2017
WASHINGTON — The seven-year Republican quest to undo the Affordable Care Act appeared to reach a dead end on Tuesday in the Senate, leaving President Trump vowing to let President Barack Obama’s signature domestic achievement collapse.
Mr. Trump declared that his plan was now to “let Obamacare fail,” and suggested that Democrats would then seek out Republicans to work together on a bill to bury the Affordable Care Act. If he is determined to make good on that pledge, he has plenty of levers to pull, from declining to reimburse insurance companies for reducing low-income customers’ out-of-pocket costs to failing to enforce the mandate that most Americans have health coverage.
“It’ll be a lot easier,” Mr. Trump said at the White House, adding: “We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it. We’ll let Obamacare fail, and then the Democrats are going to come to us.”
The fate of the repeal effort looked to be sealed on Tuesday, when a last-ditch attempt to force a vote to abolish the health law without a replacement fell short of support. The majority leader, Senator Mitch McConnell of Kentucky, seemed resolved to force senators to vote next week, but by Tuesday afternoon, it was clear he did not have 50 votes even to clear a procedural hurdle before considering a repeal-only measure.
Senators Shelley Moore Capito of West Virginia, Susan Collins of Maine and Lisa Murkowski of Alaska, all Republicans, declared that they would not vote to repeal the Affordable Care Act without a replacement: enough to doom the effort before it could gain any momentum. Senator Rob Portman, Republican of Ohio, also rejected that path.
The collapse highlighted a harsh reality for Senate Republicans: While they freely assailed the health law when Mr. Obama occupied the White House, they could not come up with a workable plan to unwind it that would keep both moderate Republicans and conservatives on board. It was an enormous embarrassment for a party that rode electoral waves to control first the House, then the Senate and then the White House, but has not been able to deliver a major legislative victory.
“This has been a very, very challenging experience for all of us,” Mr. McConnell said. “Everybody’s given it their best shot, and as of today, we just simply do not have 50 senators who can agree on what ought to replace the existing law.”
The reaction on Wall Street was muted. Stocks spent most of the day lower as shares of health insurers declined, and the dollar, which has steadily lost ground for most of the year, slipped further.
Mr. Trump has considerable leverage to gum up the works of the Affordable Care Act. He could throw insurance markets into a tailspin at any time by cutting off the subsidy payments to insurers, as he has threatened to do. He could further destabilize the markets by not enforcing the mandate that most Americans have health insurance.
And he could cancel advertising and other efforts to encourage enrollment under the Affordable Care Act when the annual sign-up period begins in November. A barrage of negative statements from the administration could project an official view that the health law is collapsing, creating a self-fulfilling prophecy.
The lack of certainty over the subsidy payments, which go toward reducing out-of-pocket costs for low-income people, has been a major concern for insurers. The companies say premiums will be significantly higher without the funding, and some companies that have submitted rates to sell insurance in the market next year could decide to pull out.
“With open enrollment for 2018 only three months away, our members and all Americans need the certainty and security of knowing coverage will be available and affordable for them,” said Justine Handelman, a senior executive at the Blue Cross Blue Shield Association.
While Mr. Trump has promised destruction, other Republicans signaled that they wanted to take a more constructive approach. Senator Lamar Alexander of Tennessee, chairman of the Senate health committee, announced that he would hold hearings in the next few weeks on stabilizing the individual health insurance market.
Members of both parties have ideas about how to stabilize insurance markets and hold down premiums. One possible action is to provide money for the payments to insurers for reducing customers’ out-of-pocket costs. In addition, two Democratic senators, Thomas R. Carper of Delaware and Tim Kaine of Virginia, want the federal government to help pay the largest claims through a backstop known as reinsurance. Senators of both parties also want to help people in counties where no insurer chooses to offer health plans through the Affordable Care Act marketplace — a real possibility in some places next year.
The Senate Democratic leader, Chuck Schumer of New York, implored Republicans to defy Mr. Trump and work with Democrats to strengthen insurance markets.
“There’s a fork in the road for our Republican colleagues,” he said in an interview. “They can do what Donald Trump said, which is sabotage the system out of anger and out of pique,” or they can work with Democrats on improvements to the health law.
“Whether they can resist Trump, I don’t know,” Mr. Schumer said.
On Capitol Hill, Republicans and Democrats alike were trying to make sense of the repeal effort’s apparent downfall — and figure out what comes next.
The beginning of the end was on Monday night, when two Republican senators, Mike Lee of Utah and Jerry Moran of Kansas, came out in opposition to the latest version of Mr. McConnell’s bill to repeal and replace the health law. That left Republican leaders at least two votes short of what they needed to start debate.
Two other Republican senators, Ms. Collins and Rand Paul of Kentucky, had objected last week.
Mr. McConnell responded by outlining plans for a vote on a measure like the one vetoed by Mr. Obama in January 2016, which Mr. McConnell said would consist of a “repeal of Obamacare combined with a stable, two-year transition period.”
Republican leaders had originally intended to proceed with a similar “repeal and delay” strategy after Mr. Trump won the presidency. But in January, Mr. Trump made clear he wanted a simultaneous repeal and replacement of the law, and congressional Republicans decided to follow that path.
A repeal-only route would have been disruptive. The Congressional Budget Office said in January that enacting the vetoed bill would increase the number of uninsured Americans by 18 million in the first year and 32 million by 2026, compared with current law. Premiums, it said, would increase 20 to 25 percent in the first year and double by 2026.
That bill would have eliminated the Affordable Care Act’s expansion of Medicaid and subsidies for the purchase of private insurance. But it would have left in place the law’s requirement that insurers provide specific benefits, and the prohibition on denying coverage or charging higher premiums because of a person’s pre-existing medical conditions.
The repeal-only idea quickly ran into a wall on Tuesday.
“I did not come to Washington to hurt people,” Ms. Capito said in a statement, taking issue with both Mr. McConnell’s bill and the idea of repealing the health law “without a replacement plan that addresses my concerns and the needs of West Virginians.”
Ms. Murkowski said, “There’s enough chaos and uncertainty already, and this would just contribute to it.”
The idea of repealing the health law without providing a replacement also spooked a bipartisan group of 11 governors, including Brian Sandoval of Nevada, an influential Republican critic of Mr. McConnell’s bill.
“The Senate should immediately reject efforts to ‘repeal’ the current system and replace sometime later,” said the group, which included five Republicans, five Democrats and one independent. “This could leave millions of Americans without coverage. The best next step is for both parties to come together and do what we can all agree on: fix our unstable insurance markets.”
Mr. McConnell appears determined to drive the effort to a final public showdown with a procedural vote that would let the Senate consider the repeal-only measure. He can afford to lose only two Republican senators, with Vice President Mike Pence breaking the tie. But he already appears to have lost at least three: Ms. Collins, Ms. Murkowski and Ms. Capito.
More could still defect, unwilling to be recorded voting for a procedural step in what is all but certain to be a doomed exercise. But that could be an awkward stance for Republicans who voted for the repeal bill that the Senate passed in 2015 and Mr. Obama vetoed.
“If you’re not willing to vote the same way you voted in 2015,” Mr. Paul said on Tuesday, “then you need to go back home, and you need to explain to Republicans why you’re no longer for repealing Obamacare.”
How the Senate Health Care Bill Failed: G.O.P. Divisions and a Fed-Up President
by Jennifer Steinhauer, Glen Thrush and Robert Pear - NYT - July 18, 2017
WASHINGTON — President Trump was fed up with the grind of health care legislation, and at a dinner with Republican senators on Monday at the White House, he let them know it. He told the lawmakers how annoyed he was with one Republican who was not there, Senator Rand Paul of Kentucky, who had gone on television over the weekend to oppose a Senate health care bill that once held the promise of victory for Mr. Trump.
It is one thing to vote no, Mr. Trump told the group, according to one of the guests. It is another, the president said, to go on all of the Sunday shows and complain about it.
The scene on Monday night was an exasperating end for Mr. Trump to a month of negotiations between the White House and Senate Republicans in an effort to repeal the Affordable Care Act, President Barack Obama’s signature domestic legacy.
The Senate bill, which faced a near-impossible path forward after the House passed its version of the legislation in May, was ultimately defeated by deep divisions within the party, a lack of a viable health care alternative and a president who, one staff member said, was growing bored in selling the bill and often undermined the best-laid plans of his aides with a quip or a tweet.
Governors, especially Republicans from states that had expanded Medicaid under the Affordable Care Act, also played a vital role in the demise of Mr. Trump’s plans. “In our state,” said Gov. John Kasich of Ohio, a Republican, “many people on Medicaid expansion are on the program for just a year and a half, until they get a job. They are not on it for 20 years. They are not lazy or committing fraud.”
The effort by Senate Republican leaders to remake the nation’s health care system — which went well beyond the perimeters of Mr. Obama’s health care law — was in retrospect doomed from the moment it began, even with the wind of an unlikely win in the House at their backs.
The Senate measure would impose annual caps on Medicaid spending, ending what has been an open-ended entitlement for the poor and disabled. The process bypassed committees, any public airing of the bill or formal bill drafting. Instead, Senator Mitch McConnell of Kentucky, the majority leader, farmed out the remaking of 17 percent of the economy to a small group of senators, all Republican white men. The bad first look did not fade.
But under fire for the all-male panel, Mr. McConnell reduced it to little more than a kaffeeklatsch, open to anyone who wanted to come by and chat health care.
Republican senators, reflecting the divide in the party, quickly formed two camps: those who wanted to squeeze hundreds of billions of dollars out of Medicaid, and those, mainly from states that had expanded the program, who wanted to preserve it. Both groups held constant meetings, with many usually conservative senators like Jerry Moran of Kansas and Charles E. Grassley of Iowa sliding into the moderate group’s gatherings to quietly voice their own concerns.
Senator Rob Portman of Ohio, in particular, formed the spine of opposition to the bill, and pushed for changes to reduce the cuts to Medicaid. In his state, more than 700,000 low-income people have gained coverage through the expansion of Medicaid under the Affordable Care Act.
Senator Susan Collins of Maine criticized the Trump administration’s often specious descriptions of what the bill would actually do, bolstering other more quiet critics’ resolve.
“The only change that Obamacare made in Medicaid was to give states the option of expanding coverage with increased federal funding,” said Ms. Collins, who opposed the Senate legislation. “Yet the Senate bill would have cut hundreds of billions of dollars from this program, imposed an entirely new formula and reduced the reimbursement rate below the cost of medical inflation.”
The changes, she added, “would have been made without the Senate holding a single hearing to evaluate the consequences on some of our most vulnerable citizens, rural hospitals and nursing homes.”
Mr. McConnell in the meantime did not have enough reliable allies on the right. Mr. Paul made it clear from the start that he would not support anything but a full repeal of the law. Senators Mike Lee of Utah and Ted Cruz of Texas had repeated conversations with Republican leaders and the White House about how to make the bill sufficiently conservative. Senator Dean Heller, Republican of Nevada, dealt an early blow by suggesting he would not support the bill.
Making matters worse for the White House, the bill had virtually no support from health care, insurance, patient advocate and disease groups, and was harshly judged by the Congressional Budget Office. Grass-roots opposition to the bill — aided by Democrats like Senator Chuck Schumer of New York — swayed members of Congress in a way rarely seen on Capitol Hill.
At the annual meeting of the American Hospital Association in May, Mr. Schumer, the Senate Democratic leader, urged hospital executives to mobilize their employees in an effort to defeat the bill, which had been approved by the House just a few days earlier.
“You have every right to express your outrage on behalf of the people who you take care of and your employees,” Mr. Schumer told hospital leaders. “Everyone needs to speak up and let their elected officials know how bad this bill is.”
The final efforts for the bill began to unravel over the weekend as several Republican senators began to balk at the legislation. Although the Trump administration had dispatched Seema Verma, the new administrator of the Centers for Medicare and Medicaid Services, to the summer meeting of the National Governors Association in Providence, R.I., to try to persuade governors — and, by extension, the senators in their states — of the bill’s merits, the governors remained unmoved.
By Saturday night, aides to Senator John McCain of Arizona, who is recovering from surgery, announced that he was unable to return from Phoenix this week, leaving Republican leaders another vote short.
By Monday night, as Mr. Trump was meeting with the group of Republican senators at the White House — not one of whom was on the fence about the bill — Mr. Moran and Mr. Lee, two senators who were on the fence, issued statements saying they would not support it, a catastrophe for the White House.
Late Monday, Mr. McConnell responded by vowing to pass a measure to repeal the Affordable Care Act now, then work on a replacement over the next two years. But on Tuesday, three Republican senators — Ms. Collins, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska — told Mr. McConnell they would not support his last-ditch effort.
Ms. Capito has generally been an ally of Republican leaders on even really tough votes and once told colleagues that the nearly 180,000 people on Medicaid in her state outnumbered the total number of people who had voted for her.
On Tuesday in Kansas, citizen-activists like Courtney Eiterich, 42, of Lenexa, who has multiple sclerosis, were celebrating outside Mr. Moran’s office in Olathe. “I’ve never done this level of political activism before,” said Ms. Eiterich, who had been dogging Mr. Moran for months. “But if I’m not speaking out, who’s going to do it?”
Mr. Kasich, who had been against the bill, was pleased with the outcome on Tuesday, and recalled conversations he had with Mr. Portman.
“I told him all the time, this is not just about opiates, though opiates are a big part of it,” Mr. Kasich said. “It’s also about people who suffer mental illness or chronic illness. Rob was trying to figure out how to be constructive, but at the same time, he didn’t want to be taken for granted in terms of his vote.”
Patient advocates, who had major concerns about the bill, were relieved.
“We joined together in January over a plate of breakfast burritos, so we call ourselves the burrito coalition,” said Sue Nelson, a vice president of the American Heart Association. “We wrote letters, we brought in patients, we talked to congressional staff until we were blue in the face. We provided members of Congress with hundreds and thousands of stories from patients to let them know how critical it was to preserve affordable health care for their constituents.”
Now what Mr. Trump once described as “an easy” process appears destined to stall his policy agenda, and has damaged his diminished standing on Capitol Hill.
Still, the White House is not giving up. Late on Tuesday, Sean Spicer, the White House press secretary, announced that Mr. Trump was inviting all Republican senators to the White House on Wednesday — to talk about health care.
Obamacare’s Future Now Depends on an Unhappy White House
by Margot Sanger-Katz - NYT - July 18, 27
The congressional effort to overhaul the health care system appears to be in shambles. But the current health care system lives on. And decisions the Trump administration makes about how to manage it could have big effects on who has coverage next year, and what it costs them.
The Department of Health and Human Services is in charge of administering Obamacare, and so far the department’s staff has given many public indications that it does not enjoy such duties.
The press office for the department can be counted on to send a news release each time there is bad news about insurers leaving markets around the country, often describing the health law’s structure as “collapsing.” It has been publishing vaguely sourced maps each week, highlighting in red the regions of the country where it says no insurers are willing to sell health plans next year.
“The situation has never been more dire,” the department’s secretary, Tom Price, said in a July 10 statement.
“Insurers continue to flee the exchanges, causing Americans to lose their choice of health insurance or lose their coverage altogether,” said Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, which oversees the Obamacare health insurance markets.
It is true that the markets are looking shaky in some places. There are regions of Nevada, Indiana and Ohio where no insurers wish to offer Obamacare plans next year. In many other locations, competition has declined. And it appears that insurers are requesting hefty rate increases in many of the places they will stay.
But the Trump administration, rather than working to solve those problems, has mostly described them as failures of the previous administration. The White House has declined to say whether it will continue to pay certain subsidies to plans for very low-income Americans, subsidies seen as vital to the financial health of the exchange business. And it has suggested that it might decline to enforce the law’s individual mandate. Both of those actions will tend to raise prices, discourage insurer participation and make Obamacare shakier than it would be otherwise.
While premiums for Obamacare plans rose sharply for many customers this year, a growing body of evidence suggests that the insurers still in the market have begun making money and would be likely to stay if not for the administrative uncertainty. So far, there has not been a widespread run for the exits among insurers, but that could change if the companies feel that the administration wishes to actively undermine the markets.
President Trump, for the moment, appears to be leaning toward that course of action. In a Tuesday morning tweet, he wrote, “Let Obamacare fail and then come together and do a great healthcare plan.” Later in the day, he told reporters that Republicans should “let Obamacare fail,” adding, “I’m not going to own it.”
Republicans control both houses of Congress and the White House. But they have demonstrated that there is not enough agreement within the party to pass a major health overhaul bill. Mr. Trump’s argument is that catastrophe in the insurance markets will be enough to bring Democrats to the negotiating table. That could be a risky strategy.
There is, of course, another possible path. The Trump administration could take actions to reassure insurers and help stabilize markets. It could promise to fund the special subsidies, at least until the end of this year. It could signal that it will instruct the I.R.S. to continue enforcing tax penalties for Americans who lack health insurance. It could promise to advertise Obamacare’s fall sign-up period, increasing the number of Americans who learn about the program and get coverage. It could reach out to carriers and insurance commissioners to help them find ways to remain in bare markets.
It has the power to minimize damage from any of the current health law’s flaws. At the moment, that does not appear to be the chosen path.
No comments:
Post a Comment